Provider Demographics
NPI:1851785885
Name:ROBERSON, HENRY EARL
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:EARL
Last Name:ROBERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1821
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-1013
Mailing Address - Country:US
Mailing Address - Phone:770-944-7280
Mailing Address - Fax:770-944-9518
Practice Address - Street 1:140 8TH ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-1310
Practice Address - Country:US
Practice Address - Phone:770-944-7280
Practice Address - Fax:770-944-9518
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-27
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0017761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003153556AMedicaid